Document name:
Safeguarding Adults at Risk
Abuse or Neglect
Document type:
Policy
What does this policy replace?
Update
of
previous
SWYPFT
safeguarding vulnerable adults policy
Staff group to whom it applies:
All staff within the Trust
Distribution:
The whole of the Trust
How to access:
Intranet and internet
Issue date:
February 2015
Next review:
February 2017
Approved by:
Executive Management Team
Developed by:
Sue Hanks
Director leads:
Director Of Nursing Compliance and
Safety
Contact for advice:
Safeguarding
328630
Team
Tel:
from
01924
Contents
Page
1
1.0
Introduction
2.0
Purpose
2
3.0
Duties
4
4.0
Definitions
7
5.0
Procedure
10
6.0
Prioritisation of Work
13
7.0
Scope of the Policy
15
8.0
Consultation, Approval and Ratification Process
15
9.0
Review & Revision Arrangements
16
Including Version Control
10.0
Dissemination and Implementation
16
11.0
Monitoring Compliance
17
12.0
References
18
13.0
Associated Documentation
18
Appendix A
Appendix B
Appendix C
1.0
1.1
Introduction
South West Yorkshire Foundation Trust is an organisation which is clear in its
mission statement that our role is to enable people (children, young people
and adults) to reach their potential and live well in the community. Our
ultimate aim is to enable individuals to make decisions in relation to their own
health outcomes.
The Safeguarding Team support the Trust Transformation process and the
principles of the Recovery Model. The Safeguarding Team acknowledge that
‘each unique individual has a unique view on what living well means to them.
Our role is to help people gain greater control and responsibility for their
future’
http://nww.swyt.nhs.uk/transformation/Pages/Recovery.aspx
The National agendas that are shaping the future of the NHS, such as the
Department of health initiative post Winterbourne to reduce restrictive physical
interventions are reflected in the ethos and practices of the safeguarding
team. The Skills for Care document (2013) Supporting staff working with
people who challenge services.
Guidance for employers suggests
‘safeguarding leads’ assist in considering situations where restrictions or
interventions are used which may or may not be ethically or legally justified’.
Some of the lessons learnt from Mid Staffordshire NHS Foundation Trust
Public Inquiry (2013) refer to ‘no tolerance of non-compliance, openness and
transparency, a level playing field of accountability and strong support for
leadership roles. This policy is underpinned by these views and directs staff
to the frameworks to assist them to deliver compassionate, individualized
care.
There will be times in an individual’s life when they are at risk from abuse or
neglect. It is an individual’s right to make their own lifestyle choices but there
will be certain times they will need extra support, for example safeguarding is
mainly aimed at people with care and support needs who maybe in vulnerable
circumstances and at risk of abuse or neglect by others. This may be when
they are deemed not to have capacity or there may be suggestion of coercion
by a third party. We will work to prevent abuse and neglect but where abuse
or neglect is suspected or known, staff will understand their obligations (and
under which circumstances) to raise a concern to the local authority to allow
them to execute their responsibilities.
1.2
SWYPFT are committed to ensure that the principles of safeguarding:
empowerment, prevention, proportionality, protection, partnership and
accountability are pivotal in decision making and in the coproduction of plans
of care.
1.3
Empowerment of the service user and ensuring that the service user’s wishes
and their aspired outcomes are at the heart of any ‘decision making’ process
is a ‘constant’ underpinning all this policy. Bearing this is mind staff need also
to be aware of and act in accordance with the principles laid down in the
1
Mental Capacity Act (2005) and SWYPFT guidance on how to interpret and
document this legislation.
www.swyt.nhs.uk/mental-health-law/documents/mca-cp.pdf
1.4
The local authority is the lead agency with regards to Safeguarding Adults
from abuse or neglect. South West Yorkshire Foundation Trust are committed
to providing safe services through the frameworks of CQC Fundamental
Standards of Quality and Safety regulation 13.
1.5
South West Yorkshire Partnership NHS Foundation Trust accepts the
principles laid down within the West Yorkshire’s Multi-Agency Safeguarding
Adults policy and procedures 2013 and the South Yorkshire Policy and
Procedures 2014 documents, and is committed to working in partnership.
1.6
The Trust expects each member of staff to work in partnership with service
users and other agencies who have signed up to the Multi-Agency Policies
and Procedures. This document is written to support staff in discharging their
duty to prevent abuse occurring where possible, recognise and identify abuse
and effectively report abuse as identified within the appropriate local authority
policy and procedure. This document describes how the organisation will
provide a clear process to ensure that staff are aware of and know how to
implement policies, protocols and guidelines and how to access the current
version with certainty. It describes how the procedural document will be
monitored and reviewed.
2.0
Purpose
2.1
The purpose of the policy is for staff to understand safeguarding within the
context of legislation, compliance and professional responsibility. They will
understand the requirement to work within the Multiagency Policies and
Procedures and that the CQC framework offers an additional framework
within which to work.
2.2
The policy replaces the previous single agency policy and signposts to two
updated Multiagency policies. This policy is developed in the context of
(i)
Explicit Safeguarding Responsibilities for the local authority as lead
provider are now outlined in the Care Act (2014) (implemented as per
April 2015). There is a duty to refer any suspected or known abuse to
the local authority where the following conditions apply:-
The Care Act (2014) (Part 1 Section 42)
1.
Enquiry by Local Authority
This section applies where a Local Authority has reasonable cause to suspect
that an adult in its area (whether or not ordinarily resident there)a)
has needs for care and support (whether or not the authority is meeting
any of those needs)
2
b)
is experiencing or is at risk of abuse or neglect and
c)
as a result of those needs is unable to protect himself or herself against
the abuse or neglect or risk of it
2.3
The local authority must make (or cause to be made) whatever enquiries it
thinks necessary to enable it to decide whether any action should be
taken in the adult’s case. The Multiagency policies and procedures provide
comprehensive guidance for staff this policy will ensure that all staff
understands that the local authority has the legal duty to investigate
allegations of abuse or neglect and are aware the correct process for
raising a concern into the local authority.
2.4
The purpose of this policy is to provide a clear and effective system for staff
to follow in order to safeguard adults at risk from abuse or neglect, where
abuse has occurred, to prevent or minimise the risk of future abuse.
The main objectives are to:Ensure there is an effective process for staff to follow ensuring the guidance
laid down within this policy is contemporary to each local authority policy on
the Safeguarding Adults at Risk of Abuse or Neglect.
Ensure staff work within the local authority Multi-Agency Policy and Procedure
relevant to their working locality.
Describe how this policy will be monitored.
In addition the organisation has a duty to ensure that adults are safeguarded
from abuse the legal framework are required to adhere to is the Fundamental
Standards of Quality and Safety (Care Quality Commission 2015).
This policy makes the duties of staff groups explicit against these standards
and outlines internal processes that sit outside the multiagency safeguarding
adults policy framework CQC compliance -Fundamental Standards of Quality
and Safety regulation 13.
3.0
Duties
The Trust has a Duty of Care in relation to safeguarding adults from abuse or
neglect.
3.1
Duties within the Organisation
Executive Management Team (EMT)
The Executive Management team approves this policy and in doing so has
signed up to the principles of the implementation of the local authorities’
Safeguarding Adults at risk of abuse or neglect policies.
Lead Director
3
The Director of Nursing, Clinical Governance and Safety is the lead director
for this policy and the Multi-Agency Safeguarding Adults at risk of abuse or
neglect policies. The Director of Nursing, Compliance and Safety and the
Assistant Director of Nursing have the responsibility of attending the MultiAgency Safeguarding Boards. Their role is to ensure decisions made by the
Multi-Agency Safeguarding Boards are incorporated into the process for the
development of this procedural document. Director members of the
Safeguarding Board will nominate relevant staff to contribute to Safeguarding
Adults Reviews (formerly Serious Case Reviews) as necessary. The lead
Director will ensure partner agencies are aware of who to contact in relation to
safeguarding concerns (Designated Adult Safeguarding Manager).
Assistant Director
The Assistant Director has responsibility for the management and governance
of the Safeguarding team, whilst supporting the Director to deliver on the
Safeguarding agenda for the Trust.
Directors
District Service Directors have the lead in ensuring this policy is cascaded to
Business Delivery Units (BDUs) and Trustwide Action Groups (TAGS). The
same groups will also have a role in implementing the procedural document.
Specialist Staff
The Specialist Adviser for Vulnerable Adults with support from the
safeguarding team is responsible for the co-ordination of the development of
the policy and its implementation through the Trust Action Group and in
addition has a lead on the development of training which supports the
implementation of this document.
The Specialist Adviser is responsible for ensuring Directors are made aware
of issues that occur within their localities as they arise.
The Specialist Adviser scans all incidents reported on the DATIX system and
alerts the Directors to any trends.
The Specialist Adviser will provide reports to the BDUs throughout the year
that will include lessons learnt, performance management and changes to
policy and procedures.
Quarterly reports are submitted to the Executive Management Team (EMT)
and board within the compliance and quality report and an annual report that
incorporates the above information will be submitted to the Clinical
Governance Committee for scrutiny as a sub group of the Trust Board by the
Specialist Adviser for Vulnerable Adults.
4
Service Managers
Service managers will ensure the policy is implemented in practice. They will
ensure positive and reactive strategies ensure people are safeguarded
thereby enacting the requirements of this policy.
Professional / Clinical Leads and Matrons
All professional /clinical Leads and matrons have a leadership role within
safeguarding, first and foremost ensuring high quality care and service
delivery for children, young people and adults. They should be able to advise
on the referral processes and signpost staff to the safeguarding team or local
authority as required.
They can provide a first level of advice where they feel able, referring onto the
safeguarding team due to a presenting issue or complexity of the case.
Clinical Leads and Matrons should have robust oversight of Patient Safety
Issues and ensure that appropriate concerns are raised into safeguarding.
Particular areas for consideration are nutrition, falls, and pressure ulcer
prevention, managing violence and aggression and transition pathways.
Practice Governance Coaches
Practice Governance Coaches will enable staff to deliver on the care agenda
which supports safeguarding. They will do this by supporting staff to
proactively assess and plan for care, ensuring risk management is intrinsic to
process. In addition practice governance coaches can remind staff of policies
which facilitate high quality care and manage risk, Did Not Attend policy,
transitions policies etc. They have a role in identifying barriers to the
achievement of those factors and enable them to be effectively raised,
providing support for problem solving where required. Practice Governance
Coaches will advise staff on raising concerns into safeguarding, and support
person centred approaches by coaching people through the decision making
process. Practice Governance Coaches will advise staff to contact the
safeguarding team when they feel that they cannot advise appropriately due
to the presenting issue or complexity of the case.
Practice Governance Coaches will horizon scan across the organisations to
risk assess any temporary deficiencies in care pathways or partnerships,
(reduced leadership, management oversight, sickness, high volume of service
demand) and ensure robust planning arrangements are put in place to
manage the risk for service users.
Staff
5
All staff are aware of this policy and the Multi-Agency Safeguarding Adults
policy and procedures and the impact it has on their practice. If any members
of staff are aware of difficulties in following the procedural document they
must alert their line manager as soon as is practical. It is everyone’s business
to report abuse. Staff members continue to have responsibility to safeguard
the person and reduce risk i.e. via care plans and participation in the
safeguarding process.
Registered professionals also need to be aware of their accountability and
registration requirements as stipulated by their governing bodies ie Nursing
and Midwifery Council, HCPC etc
Information regarding
‘Whistleblowing’ Policy.
‘whistleblowing’
is
highlighted
in
the
Trust’s
3.2
Consultation and Communication with Stakeholders
3.3
The organisation recognises that procedural documents need to be developed
in consultation with a range of stakeholders. Stakeholders have included
Yorkshire Police, Members of Safeguarding Boards, and Mid-Yorkshire
Hospital Trust and specialist commissioners .
Approval of this Document
The executive management team is responsible for final approval of all Trust
procedural documents. The Director of Nursing, Innovation and Compliance is
responsible for placing this procedural document on the EMT agenda. Multi
Agency procedural documents have been approved by the Safeguarding
Boards of which the Trust is a member.
4.0
Definitions
Definition
Procedural
document
This includes any policy, procedure, protocol or guideline that is trust wide.
Multi-Agency
documents
Procedural documents the trust has signed as a partner agency to use. This
includes the local authority Safeguarding Adults at Risk of abuse of neglect Policy
and Procedures for both West Yorkshire and South Yorkshire.
Adult at Risk of abuse or harm (formerly Vulnerable Adult)
Adult at risk The safeguarding duties apply to an adult who:
of abuse or • has needs for care and support (whether or not the local authority is meeting any of
neglect
those needs) and;
•is experiencing, or at risk of, abuse or neglect; and
6
•as a result of those care and support needs is unable to protect themselves from
either the risk of, or the experience of abuse or neglect.
(Chapter 14 Page 229 Care Act (2014) Guidance replaces the Department of
Health (2000) No Secrets Document )
Abuse is a violation of an individual’s human and civil rights by another person or
persons (No Secrets 2000). This may include physical, sexual, psychological,
financial or discriminatory abuse. The Care Act 2015 state staff should not limit their
views of what constitutes abuse or neglect.
Abuse
Raising
concern
a Informing relevant manager that a person: has been abused, is being abused or is at
risk of being abused
Domestic
Abuse
The Government definition of domestic violence and abuse is:
'Any incident or pattern of incidents of controlling, coercive or threatening behaviour,
violence or abuse between those aged 16 or over who are or have been intimate partners or
family members regardless of gender or sexuality. This can encompass, but is not limited to,
the following types of abuse: psychological, physical, sexual, financial, emotional
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/142701/guideon-definition-of-dv.pdf
Deprivation
of
Liberty
Safeguards
Dols
The deprivation of liberty safeguards were introduced to provide a legal framework
around the deprivation of liberty. Specifically, they were introduced to prevent
breaches of the European Convention on Human Rights (ECHR) such as the one
identified by the judgment of the European Court of Human Rights (ECtHR) in the
case of HL v the United Kingdom3 (commonly referred to as the ‘Bournewood’
judgment). And more recently the Cheshire West verdict.
http://nww.swyt.nhs.uk/mental-health-law/Pages/Deprivation-of-LibertySafeguards.aspx
PREVENT
Prevent is part of the Home Office and Department of Health agenda.
The aim of Prevent is to stop people from becoming terrorists or supporting
terrorism. Three national objectives have been identified for the Prevent strategy:
•Objective 1: respond to the ideological challenge of terrorism and the threat we face
from those who promote it
•Objective 2: prevent people from being drawn into terrorism and ensure that they
are given appropriate advice and support
•Objective 3: work with sectors and institutions where there are risks of radicalisation
which we need to address.
7
The health sector contribution to Prevent will focus primarily on Objectives 2 and 3.
Safeguarding Each local authority must establish a Safeguarding Adults Board (an “SAB”) for its
Board (SAB) area.
(2)The objective of an SAB is to help and protect adults in its area in cases of the
kind described in section 42(1).
http://www.legislation.gov.uk/ukpga/2014/23/section/43/enacted
The Board consists of representatives from different agencies: such as police, Local
Authority, Ambulance service, Fire and Rescue, Health, Housing, Clinical
Commissioning Group
CQC
Fundamental
Standards of
quality and
Safety
13.—(1) Service users must be protected from abuse and improper treatment in
accordance with this regulation.
(2) Systems and processes must be established and operated effectively to prevent
abuse of service users.
(3) Systems and processes must be established and operated effectively to investigate,
immediately upon becoming aware of, any allegation or evidence of such abuse.
(4) Care or treatment for service users must not be provided in a way that—
(a) includes discrimination against a service user on grounds of any protected
characteristic (as defined in section 4 of the Equality Act 2010) of the service user,
(b) includes acts intended to control or restrain a service user that are not necessary to
prevent, or not a proportionate response to, a risk of harm posed to the service user or
another individual if the service user was not subject to control or restraint,
(c) is degrading for the service user, or
(d) significantly disregards the needs of the service user for care or treatment.
(5) A service user must not be deprived of their liberty for the purpose of receiving care
or treatment without lawful authority.
(6) For the purposes of this regulation—
“abuse” means—
(a) any behaviour towards a service user that is an offence under the Sexual Offences
Act 2003(1),
(b) ill-treatment (whether of a physical or psychological nature) of a service user,
(c) theft, misuse or misappropriation of money or property belonging to a service user, or
(d) neglect of a service user.
(7) For the purposes of this regulation, a person controls or restrains a service user if
that person—
(a) uses, or threatens to use, force to secure the doing of an act which the service user resists, or
b) restricts the service user’s liberty of movement, whether or not the service user
resists, including by use of physical, mechanical or chemical means.
Single
A single agency policy which states the high level requirements for safeguarding and
Agency
signposts staff to the relevant procedures
Safeguarding
8
Policy
Mental
The Mental Capacity Act 2005 (the Act) aims to empower and protect people who
Capacity Act may not be able to make some decisions for themselves. It also enables people to
(2005) MCA plan ahead in case they’re unable to make important decisions in the future.
The Act applies to anyone aged 16 or over in England and Wales.
If a person lacks the capacity to make decisions, and they have not made advance
plans for this situation, the Act allows someone else to make that decision for them.
A person is deemed to lack capacity if they cannot, due to their illness or disability:
•understand information given to them to make a decision
•retain that information long enough to be able to make the decision
•use or weigh up the information to make the decision
•communicate their decision
http://nww.swyt.nhs.uk/mental-health-law/Pages/Mental-Capacity-Act.aspx
Datix
The Trust patient safety reporting system. All incidents that have had a Safeguarding
alert to the Local Authority required a Datix report to be completed
Safeguarding The Care Act 2015 defines the circumstances under which a SAB must conduct a
Adults
SAR as “there is reasonable cause for concern about how the SAB, members of it or
Reviews
others work together to safeguard the adult and death or serious harm arose from
actual or suspected abuse.”
Domestic
Homicide
review
(DHR)
Domestic Homicide review means a review of the circumstances in which the death
of a person aged 16 or over has, or appears to have, resulted from violence abuse
or neglect by:
a) A person to whom he was related to or with whom he was or had been in an
intimate personal relationship, or
b) A member of the same household as himself, held with a view to identifying
the lessons learnt from the death.
https://www.gov.uk/government/publications/revised-statutory-guidance-forthe-conduct-of-domestic-homicide-reviews
5.0
Procedure - Each step of the process is supported by local
documentation or flowcharts which have been designed by the LSAB
and are available via the intranet safeguarding adults’ webpage and as an
9
appendix to this policy . Following this procedure does not take the
responsibility away from the staff team for keeping the person safe. Care
planning and managing risk must be ongoing as usual.
Reporting Abuse
5.1
All staff who observe abuse or who have a concern in relation to a service
user will report those issues as soon as possible to their line manager (unless
they suspect that the manager is implicated.) In such a situation they must
report on to a more senior manager as soon as possible.
5.2
The line manager will, at the earliest possible opportunity, engage with the
appropriate lead person within Social Services and/or the police depending on
the type of concern and nature of the allegation. See “useful contacts” for the
telephone numbers. (Appendix B)
5.3
If the issue appears to involve a crime the Police will be contacted as soon as
possible. It is not necessary to wait for a safeguarding section 42 meeting to
take place or the go ahead from a lead person. Great care must be taken to
ensure evidence is not contaminated - this may require the sealing off of
areas and the isolation of individuals. If it is necessary to inform the Police as
a matter of urgency the line manager for that department or the on call
manager should be informed as soon as possible.
5.4
Where staff are concerned that the abuse or neglect is linked to poor practice
within the organisation support / guidance in relation to reporting concerns
within the Trust is available within the Trust’s “Whistle Blowing” policy.
5.5
If the line manager is unclear as to the appropriate person/agency to be
contacted, advice will be sought from the Trust’s Specialist Adviser for
Vulnerable Adults or the safeguarding team.
5.6
Each district Multi-Agency Safeguarding policy states the process in relation
to reporting, recording, and the process for dealing with alleged abuse and
alerting other agencies. These local policies must always be followed. To
enable staff to work within local procedures flowcharts are available on the
intranet safeguarding adult’s webpage and as an appendix to this policy.
5.7
Through liaising with Social Services it will be identified who is the appropriate
person to co-ordinate the safeguarding investigation process. This may be if
a crime the police, Safeguarding Co-ordinator or a Social Worker as a section
42 enquiry depending on the circumstances of the allegation.
5.8
An incident report form (electronic or paper) will be completed by the person
who is first alerted to the potential abuse or neglect. This form must be
completed to indicate what happened and what action has been taken i.e.
reported on to social services and if necessary also reported to the Police if a
crime is suspect. Where an incident doesn’t reach the threshold for a
safeguarding concernl to be made it must be dealt with via staff intervention
and case management.
10
All allegations of abuse will be reported as an incident and graded. For
example, if a patient is alleged to have suffered physical harm by a member of
staff this should be initially graded as serious amber level 4 or severe red
level 5.
It is advised that a body-map must be completed on Rio or system one of any
physical harm noting i.e. bruising, colouring location etc. This is located on
RIO in ‘Case Record’ then onto ‘assessments’ on the right hand side of the
screen and the physical examination form is right at the bottom of the listing.
Click run if a popup box appears, it takes a while to load. Within System one
the body map is situated under medical records.
If there is no immediate evidence of any physical harm, the allegation of
abuse, may require a lower grading after review. All allegations of abuse,
including allegations of service users abusing other service users, must be
reported as an incident and the severity graded. All allegations against staff
must be reported through this system and line manager’s informed for
consideration and action through the disciplinary process.
Consideration must be given to threshold. Incidents that result in harm will
always be taken through the Safeguarding Adults at risk of abuse or neglect
procedure. Allegations or incidents of abuse that appear to be linked to the
person’s level of understanding through illness or learning disability, that have
resulted in no harm, will be graded as a green incident. These incidents will
be given consideration as, if left to continue, they may result in poor care
standards and institutional abuse.
One person’s behaviour having a
detrimental effect on others will be addressed via staff intervention and case
management. The service manager must consider the need to report under
the Multi-Agency Safeguarding policy. This is not always appropriate if care
plans and risk management has taken place.
Where abuse is suspected and it involves an allegation against staff or is an
allegation which has the potential to be an amber or red incident consideration
should be given by the line manager to informing the Director of Nursing via
the specialist advisor, in these instances there is an obligation to inform the
Care Quality Commission directly
5.13
Multi-Agency policies will be followed. Each Safeguarding Board has its own
Multiagency Policy that staff are required to follow
West Yorkshire multi agency safeguarding adults policy and procedure 2013
(Wakefield Kirklees and Calderdale)
http://www.kirklees.gov.uk/community/yourneighbourhood/crimeSafety/pdf/safeguardingAdult
PolicyProcedures.pdf
South Yorkshire multi agency safeguarding adults Policies and Procedures
2014
http://www.proceduresonline.com/southyorks/sab/
11
5.20
Allegations or concerns relating to Trust Staff
The above process will be followed in all cases where it is alleged a member
of staff has breached their position of trust.
5.21
5.22
Actions will be guided by the procedures set out within the Trust’s
Disciplinary procedures.
Staff must ensure they maintain professional boundaries at all times,
further information is available via the Sexual Relationships policy.
5.23
Staff and others involved in caring for service users are not able to
benefit financially or inappropriately gain from a person who uses
services; unless it is in line with their service’s arrangements, which
should take account of other relevant professional guidance.
Therefore all gifts should be refused unless it causes distress to the
service user to do so. In such a case the service manager should be
informed of the gift to enable appropriate action to be taken.
5.24
Staff should not be involved in writing wills or bequests of people who
use services.
5.25
Staff should not use the property of people who use services for
personal use.
5.26
Staff must not borrow money from, or lend money to, people who use
services. Nor should they sell or dispose of goods belonging to people
who use services for their own gain.
5.27
The disciplinary process of investigation of staff abuse will be a joint
one with the investigator and a senior member of staff supported by
Human Resources and the Specialist Advisor - Vulnerable Adults.
5.28
If at any time the process indicates that a crime may have taken place
the investigation must be stopped until the police have been contacted
and advice on how to proceed has been received. This advice will be
documented and included within the report of the findings.
5.29
Any staff who have been identified as abusing their position of trust or
intentionally causing harm to service users will be reported via the
Disclosure and Barring Service process as part of the disciplinary
process.
https://www.gov.uk/disclosure-barring-service-check/overview
5.30
Reporting abusers to the DBS
It is the duty of the General Manager who chairs the disciplinary
procedure to make a referral to DBS immediately on making the
decision to discipline a member of staff for abuse. This process will be
12
supported by the safeguarding adults’ specialist adviser or the
safeguarding children’s lead nurse.
Jobs that involve caring for, supervising or being in sole charge of
children or adults may require an ‘enhanced DBS check with a check of
the barred lists’.
This will check whether someone’s included in the 2 DBS ‘barred lists’
(previously called ISA barred lists) of individuals who are unsuitable for
working with: Children, Adults. People on the barred lists can’t do
certain types of work. There are specific rules for working in places
where there are children - known as working in a regulated activity with
children. These are different than the rules for regulated activities for
adults.
5.31 Where individuals choose to leave the organisation prior to an
investigation the Trust must complete the process and, wherever
necessary, make the necessary referral to DBS
Employers must refer someone to DBS if they: have terminated their
employment because they harmed someone dismissed them or
removed them from working in regulated activity because they might
have harmed someone were planning to sack them for either of these
reasons, but they resigned first
5.32
The Assistant Director of Nursing Compliance and Safety is to be
informed and will take action to report professional staff to their
governing body if they breached their Code of Practice
5.33
Domestic Abuse
Staff may become aware of abuse occurring within domestic settings
between partners or other family members. In such cases it may be
necessary to access both the Multi Agency Safeguarding Adults’ policy
and the Domestic Abuse Policy. It is possible for both these policies to
be in use simultaneously.
6.0
Prioritisation of Work
This protocol is prioritised by

Joint investigation into the provision of services for people with learning
disabilities at Cornwall Partnership NHS Trust. Healthcare Commission
(2006)

Investigation into matters arising from care on Rowan Ward,
Manchester Mental Health and Social Care Trust Commission for
Health Improvement (2003)
13
6.1

Risk identified from Datix reports which clearly illustrate the need for
staff to be aware of how to report abuse.

The implementation of Local Authority Multi Agency Safeguarding
Policies.

The Mid Staffordshire NHS Foundation Trust Public Inquiry Chaired by
Robert Francis QC HC 947 Report of the Mid Staffordshire NHS
Foundation Trust Public Inquiry February (2013) Executive Summary

Transforming care: A national response to Winterbourne View Hospital
Department of Health Review: Department of Health (2012)

Treating patients and service users with respect, dignity and
compassion Department of Health 2013

Domestic violence and abuse: how health services, social care and the
organisations they work with can respond effectively NICE (February
2014) http://www.nice.org.uk/Guidance/PH50/chapter/glossary#

Care Act Chapter 23 (2014)

Care and support Statutory Guidance Department of Health 2014
Identification of Stakeholders
The following identifies some of the individuals, groups and
organisations that the Trust has consulted with, but the list is not
exhaustive.
Stakeholder
Possible level of involvement
Executive management team
Consultation, final approval
Directors
Allocated lead, development, consultation,
receipt, circulation
BDU’s
Development, consultation, dissemination,
implementation, monitoring
Specialist Adviser for Vulnerable Adults
Development, consultation, dissemination,
implementation
Service users/carers
Development, consultation
14
Professional groups /leadership
Child Protection Lead / Nurse Development, consultation, dissemination,
implementation
Consultants
Safeguarding Adults lead nurse
Clinical Governance Coaches
Trustwide action groups MAV TAG, Development, consultation, dissemination,
H&S TAG, Safeguarding Adults TAG
implementation
Local authority
Development, consultation
Police
Development, consultation
Other NHS trusts Mid Yorkshire Trust, Development, consultation
Wakefield PCT
6.2
Equality impact assessment – please see Appendix C
7.0
Scope of the Policy
All Trust Staff
It is the duty of all Trust Staff to work within this policy in the safeguarding of adults
at risk of harm or abuse.
8.0
Consultation, Approval and Ratification Process
8.1
Consultation Process
Safeguarding Adults TAG, Strategic Sub Group, Health and Safety Tag and Partner
Agencies have been consulted re the development of this polocy. For this document
the executive management team has been consulted.
8.2
Ratification Process
This document will be ratified by the EMT.
9.0
Review and Revision Arrangements including Version Control
9.1 Process for Reviewing a Procedural Document This document will be reviewed
in 2 years unless multi agency policy or Legislation / Government guidance indicates
need for changes to be made.
15
9.2
Version Control
This document is Version 5 Draft 4. Changes relate to introduction of Legislation
Integrated governance manager
The Integrated governance manager will be responsible for document control
including the recording, storing and controlling of current procedural documents and
archiving arrangements.
10.0
Dissemination and Implementation & Training Requirements
10.1
Dissemination
This document will be available via the Trust intranet and website via the
document store.

10.2
If local teams download procedural documents, they will develop a written
system for keeping this up to date that must be approved by:
Implementation of this Policy

This document will be implemented as follows

Via the Team Brief which will alert staff of this version

New staff will be informed at induction of the policy and how to access it.

The Policy and Safeguarding Policies will be available via the Trust intranet
10.3
Training Requirements
The Trust has identified that the implementation of this policy will take place via
basic awareness training. This is for all staff throughout the Trust and can be
accessed via the on line induction, which links to the Safeguarding Adults
workbook (level 1). It is mandatory training for all staff. Staff who work in direct
contact with service users who are seen as potentially adults at risk from abuse
or neglect will also undertake level 2 training. Staff must ensure they keep up to
date by accessing refresher training on a 3 yearly basis.
BDU’s are responsible for identifying those staff who are in direct contact with
adults and ensuring they have access to training.
All staff who have face to face contact with service users must discuss at
appointment and at appraisal their need for safeguarding training. It is the
responsibility of the individual and manager to ensure that staff have the requisite
competencies to carry out their role. Further advice and support can be obtained
16
from the specialist advisor and details of training can be accessed via the training
strategy and intranet pages.
Staff who work as safe guarding co-ordinators should ensure they can carry out
their role when managing safeguarding referrals by ensuring they access the
local authority training for this role
The PREVENT strategy (preventing radicalisation) also comes under the remit of
safeguarding within the Trust. Staff need to be aware of the PREVENT policy on
the intranet for guidance and training requirements.
This information can be updated / refreshed as part of the Safeguarding Adults
Training level 2 refresher.
11.Monitoring Compliance
This policy meets the external requirements Care Quality Commission
Safeguarding service users from abuse and improper treatment (Regulation 13):
Monitoring Compliance and Effectiveness

Monitoring and analysis of routine reports – e.g. incident reports, performance
reports, training uptake will be reported to the EMT.

Audit of the Trust Datix form will take place on an ongoing basis; feedback will be
given to individual staff as necessary.

Accessing statistical information from local authority leads in relation to concerns
received on an annual basis.
o The standard will be:
o All staff will follow this policy if they see or suspect abuse.
o Formal audits of the process will occur occasionally as commissioned by the lead
director. This could be delivered by internal audit or the clinical governance
support team.
12.0 References
No Secrets – Guidance on the developing of multi agency policies and procedures to
protect vulnerable adults from abuse DoH (2000)
Investigation into matters arising from the care on Rowan ward Manchester Mental
Health and Social Care Trust. Commission for Health Improvement (2003)
Joint investigation into the provision of services for people with learning disabilities at
Cornwall Partnership NHS Trust. Healthcare Commission (2006)
The Mid Staffordshire NHS Foundation Trust Public Inquiry Chaired by Robert
Francis QC HC 947 Report of the Mid Staffordshire NHS Foundation Trust Public
Inquiry February (2013) Executive Summary
Transforming care: A national response to Winterbourne View Hospital
Department of Health Review: Department of Health (2012)
Department of Health (2013)Treating patients and service users with respect, dignity
and compassion
17
Domestic violence and abuse: how health services, social care and the organisations
they work with can respond effectively NICE (February 2014)
http://www.nice.org.uk/Guidance/PH50/chapter/glossary#
Care Act Chapter 23 (2014)
Skills for Care (2013) Supporting staff working with people who challenge services.
Guidance for employers
Care and support Statutory Guidance Department of Health 2014
13.0
Associated Documentation
Disciplinary policy April (2012)
Domestic Abuse policy October (2012)
Incident Reporting and Management Procedures (including Serious Incidents)
Version 6 (2014)
Clinical Management of Aggression and Violence policy, procedures and guidance
(2012)
Policy for mandatory training (2012)
Whistle Blowing policy (2003)
Sexual Relationship policy (2012)
Safeguarding Adults multi-agency policy and procedures.
Mental Capacity Act Policy and Guidance (2008)
Deprivation of Liberty ‘Applying for a Deprivation of Liberty Safeguard (DoLS): The
Clinical Process’ (2014) http://nww.swyt.nhs.uk/mental-healthlaw/Pages/Deprivation-of-Liberty-Safeguards.aspx
PREVENT implementation Policy
18
APPENDIX A
USEFUL CONTACTS
None emergency Police 101
Forces disclosure unit 01924 295671
Emergency Police 999
BARNSLEY DISTRICT
Adults and communities Services (to raise a concern)
Tel 01226 775656
e-mail adultprotection@barnsley.gov.uk
South Yorkshire Police
Tel 01142 202020 or 101 non emergency
KIRKLEES DISTRICT
Kirklees Area Adult Protection Co-ordinator
E- Mail sarah.carlile@kirklees.gov.uk
Kirklees Police safeguarding unit
E-mail ea.safeguaring@westyorkshire.pnn.police.uk
01924 335073/72
Gateway to Care: (to raise a concern to social services)
01484414933
Emergency number out of hours 01924 326489
WAKEFIELD DISTRICT
Safeguarding Adult business Manager
Tel: 01924 302149
Social Care Direct: (to raise a concern)
0345 8 503503
Wakefield Police
Community Safeguarding team
Tel 01924 878008
E-Mail da.safeguarding@westyorkshire.pnn.police.uk
CALDERDALE DISTRICT
Adult Protection team
Tel 01422 393852
safeguarding.adults@calderdale.gov.uk
Gateway to Care on 01422 393000
Calderdale Police:
Calderdale Community Safety: 01422 318 120
Calderdale Domestic Violence/ Vulnerable Victims Co-ordinator: 01422 337 041
1
Adult Protection 01422 337041
E-mail address fa.safeguarding@westyorkshire.pnn.police.uk
TRUST WIDE
Safeguarding adults team
Fieldhead Hospital
Ouchthorpe Lane
Wakefield
WF1 3SP
Tel 01924 328630
E-Mail Sue.hanks@swyt.nhs.uk or carol.morgan@swyt.nhs.uk
Page 2
CALDERDALE INPATIENTS TEAMS
SAFEGUARDING ADULTS PROCEDURE
A Concern is raised re abuse
The person who becomes aware of the abuse or
neglect must ensure the following takes place
Take immediate steps to ensure safety ie alerting others,
seeking help, medical help.
Continue to support victim throughout process NB all grade 4
pressure sores require an automatic raising a concern to
Gateway to Care
Report to line manager
Consent given –
inform GTC
and/or police
High risk incidents of harm
must be reported to General
Manager/Director of Nursing,
Compliance and Safety
immediately.
Director of
Nursing,
Compliance and
Safety to inform
CQC
Seeking consent to report on to GTC. or the
Police.
May need to assess mental capacity –
document assessment
The person lacks
mental capacity.
Report on to GTC
and/or police in their
best interest
Consent refused.
Assess risk/seriousness. If others
are at risk OR if perpetrator is a
member of staff or volunteer
explain need and raise a concern
to GTC and/or police. Raise a
concern
Contact GTC – share relevant information. Request which team
will be allocated. (If case already known to community team inform
GTC) If concern is closed ask for outcome code. If a crime is
suspected Contact Police, share information, ask for log numbers.
Complete RiO/Datix; include
GTC/Police log number under action
taken NB complete body map form if
physical signs of abuse or neglect noted
If the case is already known to your team ensure safeguarding
procedure is followed. Ensuring locally agreed processors for
logging action is followed.
Risk team to forward Datix report to
NPSA and CQC
Gateway to Care (GTC): 01422 393000
Safeguarding Unit (Police): non emergency 01422 337041 or 101
Police (for urgent emergency response): 0845 6060606 or 999
Adviser for vulnerable adults (advice) 01924 328630
Page 3
WAKEFIELD INPATIENT AREAS
SAFEGUARDING ADULTS PROCEDURE
A Concern is raised re abuse
The person who becomes aware of the abuse or
neglect must ensure the following takes place
Take immediate steps to ensure safety ie alerting others, seeking
help, medical help.
Continue to support victim throughout process NB all grade 4
pressure sores require an automatic concern to Social Care Direct
Report to line manager
Consent
given – inform
SCD
and/or police
High risk incidents of harm
must be reported to General
Manager/Director of Nursing
Compliance and Safety
immediately.
Director of
Nursing,
compliance and
safety to inform
CQC
Seeking consent to report on to SCD. or the
Police.
May need to assess mental capacity –
document assessment
The person lacks
mental capacity.
Report on to SCD
and/or police in their
best interest
Consent refused.
Assess risk/seriousness. If others
are at risk OR if perpetrator is a
member of staff or volunteer
explain need to raise a concern to
SCD and/or police. Raise concern
Contact SCD– share relevant information. Request which team
will be allocated. If concern is closed ask for outcome code. If a
crime is suspected Contact Police, share information, ask for log
numbers.
Complete RiO/Datix; include
SCD/Police log number under
action taken NB complete body
map form if physical signs of
abuse or neglect noted
Risk team to forward
Datix report to NPSA
and CQC
Social Care Direct (SCD): 0345 8 503 503
Safeguarding Unit (Police): non emergency 01924 878008
Police (for urgent emergency response): 101
Adviser for vulnerable adults (advice) 01924 328630
Page 4
WAKEFIELD COMMUNITY TEAMS
SAFEGUARDING ADULTS PROCEDURE
A Concern is raised re abuse
The person who becomes aware of the abuse or
neglect must ensure the following takes place
Take immediate steps to ensure safety ie alerting others,
seeking help, medical help .Continue to support victim
throughout process NB all grade 4 pressure sores require
automatic concern to be raised to Social Care Direct
Report to line manager
Consent given –
inform SCD (or open a
safeguarding referral)
and/or police
High risk incidents of harm
must be reported to General
Manager/ Director of Nursing
Compliance and Safety
immediately.
Director of
Nursing,
Compliance and
Safety to inform
CQC
Seeking consent to report on to SCD (or
open a safeguarding referral). or the Police.
May need to assess mental capacity –
document assessment
The person lacks
mental capacity.
Report on to SCD
(or open a
safeguarding Sec
42) and/or report to
police in their best
interest
Consent refused.
Assess risk/seriousness. If others
are at risk OR if perpetrator is a
member of staff or volunteer
explain need to raise concern to
SCD (or open a safeguarding Sec
42) and/or police. Raise a concern
Contact SCD – share relevant information. Request which
team will be allocated. If concern is closed ask for outcome
code. If a crime is suspected Contact Police, share
information, ask for log numbers.
Complete RiO/Datix; include SCD/Police log number
under action taken NB complete body map form if
physical signs of abuse or neglect noted
Risk team to forward Datix report to NPSA and CQC
Social Care Direct (SCD): 0345 8 503 503
Safeguarding Unit (Police): non emergency 01924 878008
Police (for urgent emergency response): 101
Adviser for vulnerable adults (advice) 01924 328630
Page 5
CALDERDALE COMMUNITY TEAMS
SAFEGUARDING ADULTS PROCEDURE
A Concern is raised re abuse
The person who becomes aware of the abuse or
neglect must ensure the following takes place
Take immediate steps to ensure safety ie alerting others, seeking
help, medical help.
Continue to support victim throughout process NB all grade 4
pressure sores require an automatic concern to Gateway to Care
Report to line manager
Consent given –
inform GTC
and/or police
High risk incidents of harm
must be reported to General
Manager/ Director of
Nursing, Compliance and
Safety immediately.
Director of
Nursing,
Compliance and
Safety to inform
CQC
Seeking consent to report on to GTC. or the
Police.
May need to assess mental capacity –
document assessment
The person lacks
mental capacity.
Report on to GTC
and/or police in their
best interest
Consent refused.
Assess risk/seriousness. If others
are at risk OR if perpetrator is a
member of staff or volunteer
explain need and refer to
GTCand/or police. Raise a
concern
Contact GTC – share relevant information. Request which team
will be allocated. (If case already known to community team inform
GTC) If concern is closed ask for outcome code. If a crime is
suspected Contact Police, share information, ask for log numbers.
Complete RiO/Datix; include GTC/Police
log number under action taken NB
complete body map form if physical signs
of abuse or neglect noted
If the case is already known to your team ensure safeguarding
procedure is followed. Ensuring locally agreed processors for
logging action is followed.
Risk team to forward Datix report to
NPSA and CQC
Gateway to Care (GTC): 01422 393000
Safeguarding Unit (Police): non emergency 01422 337041 or 101
Police (for urgent emergency response): 0845 6060606 or 999
Adviser for vulnerable adults (advice) 01924 328630
Page 6
KIRKLEES COMMUNITY TEAMS
SAFEGUARDING ADULTS PROCEDURE
A Concern is raised re abuse
The person who becomes aware of the abuse or
neglect must ensure the following takes place
Take immediate steps to ensure safety ie alerting others,
seeking help, medical help.
Continue to support victim throughout process NB all grade 4
pressure sores require an automatic concern to Gateway to
Care
Report to line manager
Consent given –
inform GTC
and/or police
High risk incidents of harm
must be reported to General
Manager/ Director of
Nursing, Compliance and
Safety immediately.
Director of
Nursing,
Compliance and
Safety to inform
CQC
Seeking consent to report on to GTC. or the
Police.
May need to assess mental capacity –
document assessment
The person lacks
mental capacity.
Report on to GTC
and/or police in their
best interest
Consent refused.
Assess risk/seriousness. If others
are at risk OR if perpetrator is a
member of staff or volunteer
explain need and raise a concern
to GTC and/or police. Raise a
concern
Contact GTC – share relevant information. Request which team
will be allocated. (If case already known to community team inform
GTC) If concern is closed ask for outcome code. If a crime is
suspected Contact Police, share information, ask for log numbers.
Complete RiO/Datix; include GTC/Police
log number under action taken NB
complete body map form if physical signs
of abuse or neglect noted
If the case is already known to your team ensure safeguarding
procedure is followed. Ensuring locally agreed processors for
logging action is followed.
Risk team to forward Datix report to
NPSA and CQC
Gateway to Care (GTC): 01484 414933
Safeguarding Unit (Police): none emergency 01924 335073 or 101
Police (for urgent emergency response): 0845 6060606 or 999
Adviser for vulnerable adults (advice) 01924 328630
Page 7
BARNSLEY - SAFEGUARDING ADULTS PROCEDURE
A concern is raised re abuse
The person who becomes aware of the abuse or
neglect must ensure the following takes place
Take immediate steps to ensure safety i.e. alerting
others, seeking help, medical help.
Continue to support victim throughout process NB all
grade 4 pressure sores require an automatic
concern to be raised to adult protection
Report to line manager,
Clinical lead, Matron or
Safeguarding Manager
Seek consent to report to:
adultprotection@barnsley.gov.uk or the Police
Follow local process by completing form 1
You may need to assess mental capacity –
document assessment
Consent refused - Assess
risk/seriousness. If others are at
risk OR if perpetrator is a member
of staff or volunteer, explain need
and raise a concern to
adultprotection@barnsley.gov.uk
and/or police. Make an alert
High risk incidents of
harm must be reported to
General Manager/Director
of Nursing, Compliance
and Safety immediately.
Director of Nursing
Compliance and Safety to
inform CQC
Risk team to forward Datix
report to NPSA and CQC
The person lacks
mental capacity. Report:
adultprotection@barnsley
.gov.uk and/or police in
their best interest
Consent given:
inform
adultprotection@
barnsley.gov.uk
and/or police
Contact Adult Protection – share relevant information.
Request which team will be allocated. (If case already
known to community team – inform them) If concern is
closed ask for outcome code. If a crime is suspected
contact Police, share information, ask for log numbers.
Complete RiO/Datix; include any log
number under action taken complete
body map form if physical signs of
abuse or neglect noted
If the case is already known to your
team -ensure safeguarding procedure is
followed, including locally agreed
processors for logging action
Safeguarding Vulnerable Adults Team, Social Services: 01226 775656
Police non emergency: 101
Police for urgent emergency response: 999
Adviser for vulnerable adults (advice): 01924 328630
Page 8
FORENSIC SERVICES
SAFEGUARDING ADULTS PROCEDURE
A Concern is raised re abuse
The person who becomes aware of the abuse or
neglect must ensure the following takes place
Take immediate steps to ensure safety ie alerting others, seeking
help, medical help.
Continue to support victim throughout process NB all grade 4
pressure sores require an automatic concern to Social Care Direct
Report to line manager
Consent
given – inform
SCD
and/or police
High risk incidents of harm
must be reported to General
Manager/ Director of Nursing
Compliance and Safety
immediately.
Director of
Nursing,
Compliance and
Safety to inform
CQC
Seeking consent to report on to SCD. or the
Police.
May need to assess mental capacity –
document assessment
The person lacks
mental capacity.
Report on to SCD
and/or police in their
best interest
Consent refused.
Assess risk/seriousness. If others
are at risk OR if perpetrator is a
member of staff or volunteer
explain need and to raise a
concern to SCD and/or police.
Raise a concern
Contact SCD – share relevant information. Request which
team will be allocated. If concern is closed ask for outcome
code. If a crime is suspected Contact Police, share
information, ask for log numbers.
Complete RiO/Datix; include
SCD/Police log number under
action taken NB complete body
map form if physical signs of
abuse or neglect noted
Risk team to forward
Datix report to NPSA
and CQC
Social Care Direct (SCD): 0345 8 503 503
Safeguarding Unit (Police): non emergency 01924 878008 or 101
Adviser for vulnerable adults (advice) 01924 328630
Page 9
KIRKLEES INPATIENT AREAS
SAFEGUARDING ADULTS PROCEDURE
A Concern is raised re abuse
The person who becomes aware of the abuse or
neglect must ensure the following takes place
Take immediate steps to ensure safety ie alerting others,
seeking help, medical help.
Continue to support victim throughout process NB all grade 4
pressure sores require an automatic rconcern to Gateway to
Care
Report to line manager
Consent given –
inform GTC
and/or police
High risk incidents of harm
must be reported to General
Manager/ Director of
Nursing, Compliance and
Safety immediately.
Director of
Nursing,
Compliance and
Safety to inform
CQC
Seeking consent to report on to GTC. or the
Police.
May need to assess mental capacity –
document assessment
The person lacks
mental capacity.
Report on to GTC
and/or police in their
best interest
Consent refused.
Assess risk/seriousness. If others
are at risk OR if perpetrator is a
member of staff or volunteer
explain need and to raise a
concern to GTCand/or police.
Raise a concern
Contact GTC – share relevant information. Request which team
will be allocated. (If case already known to community team inform
GTC) If concern is closed ask for outcome code. If a crime is
suspected Contact Police, share information, ask for log numbers.
Complete RiO/Datix; include GTC/Police
log number under action taken NB complete
body map form if physical signs of abuse or
neglect noted
If the case is already known to your team ensure safeguarding
procedure is followed. Ensuring locally agreed processors for
logging action is followed
Risk team to forward Datix report to NPSA and CQC
Gateway to Care (GTC): 01484 414933
Safeguarding Unit (Police): non emergency 01924 335073 or 101
Police (for urgent emergency response): 0845 6060606 or 999
Adviser for vulnerable adults (advice) 01924 328630
Page 10
Appendix B - Equality Impact Assessment Tool
To be completed and attached to any policy document when submitted to the Executive Management Team for
consideration and approval.
Date of Assessment: ___11.12.14_____________________________
Equality Impact Assessment Questions:
Evidence based Answers & Actions:
1
Name of the document that you are
Equality Impact Assessing
Safeguarding adults at Risk from Abuse and neglect
policy
2
Describe the overall aim of your
document and context?
The overall aim of the Policy is to describe the Trust’s
approach to the safeguarding of adults
Who will benefit from this
policy/procedure/strategy?
All service users and staff
Who is the overall lead for this
assessment?
Director of Nursing, compliance and safety
3
4
Who else was involved in conducting this
assessment?
The safeguarding team
5
Have you involved and consulted service
users, carers, and staff in developing this
policy/procedure/strategy?
People involved included staff in BDU’s LA safeguarding
leads, volunteers
What did you find out and how have you
used this information?
Change of terminology
6
What equality data have you used to
inform this equality impact assessment?
Datix data
7
What does this data say?
The data indicates that staff have to be able to identify
abuse and know how to work in partnership to protect
those at risk
8
Taking into account the
information gathered above,
could this policy
/procedure/strategy affect
any of the following equality
group unfavourably:
Yes/No
8.1
Race
Yes
Those who are suffering from racial abuse will benefit
from staff understanding this policy
8.2
Disability
yes
Those seen as vulnerable due to disability will be better
supported by staff being awre of this policy
8.3
Gender
No
Page 11
Equality Impact Assessment Questions:
8.4
Age
yes
Evidence based Answers & Actions:
Older people at risk of abuse will be better supported if
staff work within this policy
8.5
Sexual Orientation
no
8.6
Religion or Belief
no
8.7
Transgender
no
8.8
Maternity & Pregnancy
no
8.9
Marriage & Civil
no
partnerships
8.10
Carers*Our Trust
no
requirement*
9
What monitoring arrangements are you
implementing or already have in place to
ensure that this
policy/procedure/strategy:-
9a
Promotes equality of opportunity for
people who share the above protected
characteristics;
Review of datix which indicate safeguarding alerts.
9b
Eliminates discrimination, harassment
and bullying for people who share the
above protected characteristics;
As above
9c
Promotes good relations between
different equality groups;
As above
9d
Public Sector Equality Duty – “Due
Regard”
Have you developed an Action Plan
arising from this assessment?
As above
10
11
No
Assessment/Action Plan approved by
Signed: Date:
Title:
12
Once approved, you must forward a copy
of this Assessment/Action Plan to the
Equality and Inclusion Team:
inclusion@swyt.nhs.uk
Page 12
Equality Impact Assessment Questions:
Evidence based Answers & Actions:
Please note that the EIA is a public
document and will be published on the
web.
Failing to complete an EIA could expose
the Trust to future legal challenge.
If you have identified a potential discriminatory impact of this policy, please refer it to the Director of
Corporate Development or Head of Involvement and Inclusion together with any suggestions as to the action
required to avoid/reduce this impact.
For advice in respect of answering the above questions, please contact the Director of Corporate Development
or Head of Involvement and Inclusion.
Page 13
Appendix C - Checklist for the Review and Approval of Procedural Document
To be completed and attached to any policy document when submitted to EMT for consideration and
approval.
Yes/No/
Unsure
Title of document being reviewed:
1.
2.
Title
Is the title clear and unambiguous?
YES
Is it clear whether the document is a guideline,
policy, protocol or standard?
YES
Is it clear in the introduction whether this
document replaces or supersedes a previous
document?
YES
Rationale
Are reasons for development of the document
stated?
3.
4.
Is the method described in brief?
YES
Are people involved in the development
identified?
YES
Do you feel a reasonable attempt has been
made to ensure relevant expertise has been
used?
YES
Is there evidence of
stakeholders and users?
EMT
consultation
with
Content
Is
the
target
unambiguous?
6.
YES
Development Process
Is the objective of the document clear?
5.
Comments
population
clear
YES
and
YES
Are the intended outcomes described?
YES
Are the statements clear and unambiguous?
YES
Evidence Base
Is the type of evidence to support the
document identified explicitly?
YES
Are key references cited?
YES
Are the references cited in full?
YES
Are supporting documents referenced?
YES
Approval
Does
the
document
identify
committee/group will approve it?
which
If appropriate have the joint Human
Resources/staff side committee (or equivalent)
YES
N/A
Page 14
Yes/No/
Unsure
Title of document being reviewed:
Comments
approved the document?
7.
8.
9.
10.
11.
Dissemination and Implementation
Is there an outline/plan to identify how this will
be done?
YES
Does the plan include the necessary
training/support to ensure compliance?
yes
Document Control
Does the document identify where it will be
held?
YES
Have archiving arrangements for superseded
documents been addressed?
yes
Process to Monitor
Effectiveness
Compliance
and
Are there measurable standards or KPIs to
support the monitoring of compliance with and
effectiveness of the document?
YES
Is there a plan to review or audit compliance
with the document?
YES
Review Date
Is the review date identified?
YES
Is the frequency of review identified? If so is it
acceptable?
YES
Overall Responsibility for the Document
Is it clear who will be responsible
implementation and review of the document?
YES
Page 15
Appendix D - Version Control Sheet
This sheet should provide a history of previous versions of the policy and changes made
Version Date
Author
Status
Comment / changes
1
June
2008
Director of Corporate
Development
Final
Final version approved by Trust Board
2
March
2009
Director of Corporate
Development
3
March
2010
Specialist
Adviser
safeguarding adults
Final
draft
Changes made following review and
subsequent
recommendations
made
during NHS LARMS review
4
March
2012
Specialist
Adviser
safeguarding adults
Draft 1
Changes made following
services from NHS Barnsley
transfer
of
4
April
2012
Specialist
Adviser
safeguarding adults
Final
Version
Changes made following
services from NHS Barnsley
transfer
of
5
July
2014
Specialist
Adviser
safeguarding adults
Draft 3
Changes made following
legislation and guidance
changes
to
5
Septem
ber 2014
Specialist
Adviser
safeguarding adults
Final
version
Changes made based on changes in
legislation and feedback from colleague’s
within the Trust and CCG.
Changes made to ensure clarity on
superseded or replaced documents and to
reflect change in guidance for 2009/10
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